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General NPI Number Information
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NPI Number | 1821451774
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Entity Type | Organization
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Legal Business Name | EDLUND DENTAL, LLC
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Dates
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Enumeration Date | 03/29/2016
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Last Update Date | 03/29/2016
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Provider Practice Location Address
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Address Line | 1021 BANDANA BLVD E SUITE #105
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City | SAINT PAUL
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State | MN
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Zip | 55108-5113
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Country | US
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Telephone | 651-645-0449
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Fax |
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Provider Business Mailing Address
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Address Line | 1021 BANDANA BLVD E SUITE #105
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City | SAINT PAUL
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State | MN
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Zip | 55108-5113
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Country | US
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Telephone | 651-645-0449
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Fax |
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Authorized Official
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Title or Position | CHIEF MANAGER
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Name | DR. STEVEN MICHAEL EDLUND
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Credential | D.D.S.
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Telephone | 651-645-0449
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D12097
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License Number State | MN
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